Care Coordination
Comparative Matrix
Technical Assistance of the Rural
Health Information Technology
Network Development (RHITND)
Grantees
August 2014
600 East Superior Street, Suite 404 │ Duluth, Minnesota 55802
Phone: 218-727-9390 │ [email protected]
Get to know us better: www.ruralcenter.org
This is a publication of the National Rural Health Resource Center. The project
described was supported by Contract Number HHSH250201100027C from the
U.S. Department of Health and Human Services, Health Resources and Services
Administration, Federal Office of Rural Health Policy.
PURPOSE
Through the National Rural Health Resource Center’s (The Center) work with the
Rural Health Information Network Development (RHITND) program and in
recognition of the accelerating pace of change in the American health care system
in its transition from volume to value-based reimbursement, The Center identified a
need to support rural health networks in awareness and understanding of emerging
care coordination models. These emerging models are innovative and strategic
solutions that address network members’ need to transition toward value-based
reimbursement.
The Center identified rural health networks that are developing or implementing
value-based models and conducted brief interviews with the network leaders that
are implementing or developing care coordination initiatives. These profiles create a
matrix that allows for comparison of the various models and features, such as, the
primary focus of the model and demographics, different combinations of the care
coordination team roles, aspects of the HIT infrastructure and lessons that these
rural health network innovators have learned during the design and implementation
of the models.
The Center used the care coordination definition crafted by the Certification
Commission for Health Information Technology (CCHIT) which is provided below,
and also asked the network’s for their own definitions:
Care coordination involves two different but related aspects of patient care.
One provides information to the clinician who must be able to access from
and provide relevant clinical data to multiple sources in order to determine
and provide for appropriate next steps in diagnosis or treatment. The other is
to assure that patients are in the appropriate setting as they transition
among multiple levels of care. Both are important for providing high quality
care as well as mitigating excess, both must incorporate patient needs and
preferences, and both are highly dependent on the ability to quickly and
easily send and query health information on a given patient to and from
multiple electronic sources.
The goal of the rural health network Care Coordination Model Comparative Matrix is
to capture and communicate this emerging knowledge to share with other rural
health networks. The matrix can be used by any rural health network to consider
aspects of the various models in order to support their own work in preparing their
members for a transition to value-based reimbursement.
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METHODS
The Comparative Matrix chart includes a brief profile of various care coordination
models that are emerging across the country. Features highlighted in the profile
include: network description, focus population, care team members, collaboration
partners, HIT, patient/family engagement and business model examples needed for
care coordination. It also includes insights on challenges and lessons learned by
each model from the perspective of implementing solutions for network members.
The information was collected through informational interviews with rural health
network leaders across the nation that are currently implementing or designing care
coordination solutions for their members.
These interviews were conducted by Terry Hill, MPA, Senior Advisor for Rural Health
Leadership and Policy at the National Rural Health Resource Center. Each voluntary
interview was about an hour in length. The interviews were summarized by the
RHITND Technical Assistance (TA) Team to fit within the matrix chart to provide an
opportunity to compare the various models. The organization and interviewee are
identified for each network profile.
Five of the nine interviews are RHITND grantee networks. Each of these grantees
utilized RHITND funds to implement HIT and network infrastructure that supports
the design and implementation of their care coordination model. The other four
networks were identified through The Center’s TA work with rural hospitals and
clinics across the country within the Technical Assistance Service Center (TASC)
and Rural Hospital Performance Improvement (RHPI) programs.
Care Coordination Profile Interview Questions
1) What is your definition of care coordination?
2) How would you describe your network?
3) What population is the focus of the care coordination?
4) Who is on your care team? (Workforce roles?)
5) Who are you partnering with to provide care? (Partner organizations?)
6) How are you using HIT to facilitate documentation of care coordination
activities, care plans, communication and data analysis?
7) How are you engaging patients and families/caregivers in the care
coordination model?
8) What is the business model? (How will you be paid?)
9) What are the greatest challenges and/or lessons learned you have
encountered during the planning and/or implementation?
10) How did you or are you overcoming these challenges?
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Rural Network Care Coordination Models: Comparative Matrix
Contact/
Location
Allevant
based on Mayo Post-Acute Care model
Community Health IT Network
Rural Health Partnerships
Critical Access Hospitals Network
Rural HIT Project
Jordan Tenenbaum and Mark Lindsay, MD
Started in Wisconsin,Minnesota,Iowa
Kendra Siler-Marsiglio and David Willis MD
Florida
Sue Dietz
Washington
Care
Coordination
Definition
-Very broadly: Teamwork: culture, communication and
collaboration
-It is process focused and involves training, education,
measurement and transparency, with the goal of getting
patients to highest level of independence, effectively and
efficiently
-Looking to improve communication between providers
and institutions as patients are be moved
-Patient also gets the information that the provider
receives (longitudinal care records) so they can also be
engaged
-Activities of a diverse group of individuals (patients,
payers, providers that serve a certain population) that
work together to achieve quality outcomes. This happens
through various activities.
Network
Description
-Multi-county and multi-state region
 Clinics
 12 CAHs in MN, WI, and IA
-Multi-county (10) in north central Florida
-They are 1 of 9 recognized Florida healthcare networks
that include primary care safety net organizations
 FQHCs
 Rural Health Clinics
 CAHs
 Rural Hospitals
 Behavioral Health providers
 AHEC
 Community colleges and universities
 Workforce development boards
 Local government boards and businesses
-Multi-county (5) in eastern Washington
-7 public hospital districts
-6 CAHs and 1 PPS hospital
-Shared network services promote operational efficiencies
and include IT infrastructures, operation infrastructures,
etc.
-Considering Medicare patients through an ACO
Focus Population
-Post-acute care patients including ventilator patients
-Focus on utilizing swing bed program for post-acute care
-Started model in Eau Claire, WI with focus on
establishing a transitional model and post-acute care
program then expanded to other states and CAHs
-Starting with diabetes patients, mental health patients,
primary care patients
-Considering VA patients
-Chronic disease patients
-Some Medicaid population (mostly under SIM grant)
-High needs and high health care utilizers
-Comorbidities and mental health
Care Team
Members
-Transitional Nurse Care Coordinator (center piece to care
coordination)
-Physician, Nurse Practitioner or Physician Assistant
-Nursing Assistant
-Therapies: Respiratory, speech and physical
-Social Services
-Dietician
-Chaplin
-Families and Patients
-Case Managers for information
-Modeled after clinical integration organization
-Primary care providers
-Care Coordinators (primarily nurses)
-Clinic staff (MA, RN)
-Therapists
-Mental Health
-Social Workers
Partner
Organizations
-Mayo Health System
-Network members (see above)
-County Health Department
-Florida Office of Rural Health
-County Health Departments
-Aging and LTC agencies
-Social Services
-Rural Resource Agencies
-Agencies supporting program improvement (DOH, etc.)
-Regional Partners
-State Office of Rural Health
NATIONAL RURAL HEALTH RESOURCE CENTER
RURAL NETWORK CARE COORDINATION MODELS: COMPARATIVE MATRIX
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Allevant
based on Mayo Post-Acute Care model
Community Health IT Network
Rural Health Partnerships
Critical Access Hospitals Network
Rural HIT Project
-Used federal Rural Health Information Technology grant
funding to implement
-Aggregating data as a region and supporting population
health analysis
 Sorting by demographics, payers, clinical indicators,
etc. to help see the gaps and who needs tracking,
follow up, etc.
 Some data used for staff performance reviews in
some hospitals
-State HIE under development
-Tele-mental health
-Exploring use of robots to support sicker patients in rural
areas; tele-remote modeling
-In development stages
-More of a clinic function than network function
-Use of patient portals, but the patients still can’t see the
data in a clean way that makes sense
-Considering: more patient education tools
HIT
-Web-based patient database
-IT portal used for team role training and education
-IT used for measurement tracking with a focus on
reducing readmissions and improving quality
-HIE use
 Combination of a longitudinal health record and a patient
portal
 Information is the same for both patient and provider
 Provider can message out to patients, prescriptions
requests, billable (by four insurers) online web visits that
are email based
 Audit log to ensure transparency, privacy and security
-Makes a robust longitudinal record to ensure quality data care
and fantastic data source
-Looking into tele-health and use in the exchange
Patient/
Family
Engagement
-Patients and family have been involved since day one
-Patients are introduced to key processes by nurse care
coordinator
-Nurse care coordinator is engaged to know the plan of
care
-At the end of bedside rounds, patient is asked a patient
centered, open-ended question
-Replicated throughout Mayo rural hospital system and
expanding throughout the nation
-Positive financial and quality outcomes for both CAHs and
referral centers
-Developing a new revenue source for CAHs to increase
census and financial viability with increased margin and
efficiency
-Can see revenue increases of $1 million with 15-55% net
margin using existing resources without adding new staff.
 Documented a 20:1 ratio of investment to return
Challenges:
 Cultural resistance to change in CAHs, and fear of
letting go of the past
 Instilling care coordination teams in hospitals
 Breaking down the silos in the communities
Lessons:
 CAHs served many more post-acute care patients
when implementing these programs
 Financial and quality outcomes were better for both
CAHs and referral centers.
 Measurement and benchmarking is important
Referral centers will refer to CAHs for post-acute care
coordination if the necessary work is done in the CAH
-Patients and families are integral to the model
- Patient engagement happens through internet, phone,
video, etc.)
-Caregiver access to parents of children, adults to their
parents, spouses, etc.
-Doing patient readiness assessments
Business Model
Challenges/
Lessons Learned
NATIONAL RURAL HEALTH RESOURCE CENTER
-Planning a subscription model
-Acting as the regional health information exchange
-Fee for service HIT assistance
-Grants and contracts
-Non-profit
-Minimal membership dues
-Heavily grant funded to date; such as SIM grants to
support shift to value based reimbursement
-Eventually user fees and service charges
Challenges:
 Getting people excited is easy, but getting them to
“sign on the dotted line” is not
 When rural entities are owned by a large health
system, it can be difficult to get them engages in
community health projects
Lessons:
 Engage community partners, businesses and
patients early on:
 Do not take a top-down approach.
 Getting physicians involved and understanding the
“why” is key to success
 Easy patient access to medical information is
essential
Local businesses are important partners and can purchase
services
Challenges:
 Breaking down barriers between hospitals and mental
health providers, and developing better communication
 Having to go through hospital boards for permission to
participate in programs
 More than one care coordinator from different entities
being assigned to the same patients
 Funding for development and implementation
 Facing the unknown and the profound changes occurring
in the market
 Lack of IT and data analytics knowledge in the rural
facilities
Lessons:
 Need to build trust and communication between mental
health and hospitals/physicians
 Networks need to increase member awareness of
changes, help connect the members to needed resources
 The data isn’t always clean or clear; it takes work to
clean it up so that it’s useful; Standardization of data
into one system is important
RURAL NETWORK CARE COORDINATION MODELS: COMPARATIVE MATRIX
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Rural Care Coordination Models: Comparative Matrix
Contact/
Location
Fort Drum Regional Health Planning Org.
North Country Health Information Partnership
Heath Care Collaborative of Rural Missouri
HIT Network
Illinois Critical Access Hospital Network
Corey Zeigler and Patricia Fralick
New York
Toniann Richard
Missouri
Angie Charlet
Illinois
Care
Coordination
Definition
-Focusing on hand-offs of patient between providers of the -Establishing integrative health by having working teams
care continuum, and involving patient and families and
across the network to maximize the current payment
focusing on the improving processes
system, and work with patients and providers in creating
a different payment model based on value
-Care coordination that is patient centered, high quality
and cost effective
Network
Description
-Multi-county, (3) in northern New York
-About 200,000 people
-6 hospitals, 22 primary care providers and 6 specialty
practices
-Clinically integrated network with focus on primary care
and behavioral health
-Social Service Agencies
-Multi-county in northeastern Missouri
-Members including:
 4 hospitals
 2 FQHCs
 Department of Mental Health
 Agency on Aging
 Health Department
 Economic development
-Multi-county across Illinois
-24 of 53 ICAHN CAHs
-Primarily diabetes and co-morbidity of diabetes and
depression
-Considering cardiovascular disease patients
-700 patients enrolled
-Multiple chronic illness patients
 CHF and heart disease
 Diabetes
 Obesity
-Private payer populations, e.g. BCBS
-Medicare patients as part of an ACO
Focus Population -Chronic conditions, preventable (re)admissions, ER
utilization, etc.
-Diabetes and Cardiovascular Disease
-Medicaid and Behavioral health
-Medicare
-Private payer populations
Care Team
Members
-Care Coaches (typically non-nurse) modeling behaviors,
using empowerment of the patient to be more engaged
(pilot Coleman model)
-Considering Social Workers, Behavioral Health and
nurses
-Physicians and Nurses
-Nurse (community outreach focus)
-Nurse Practitioner
-Physician
-Dental Hygienist
-Clinical Social Worker,
-Psychologist,
-Psychiatrist and Sociologist (focus on rural cultural
competency issues)
-Patient educators
-Physicians
-Case Managers
-Nurses
-IT
-Informaticists
-Community Health Workers
-Social Workers
Partner
Organizations
-Hospitals
-Primary care clinics
-Physicians
-Substance abuse and Behavioral Health
-Public Health
-Area Agency on Aging
-Mental Health Organizations
-Multi-county community action agencies
-Migrant Farm Workers
-Probation Referral
-Kansas University research
-REACH Foundation
-Rural hospitals
-Exploring partnerships with private third party payers
NATIONAL RURAL HEALTH RESOURCE CENTER
RURAL NETWORK CARE COORDINATION MODELS: COMPARATIVE MATRIX
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Fort Drum Regional Health Planning Org.
North Country Health Information Partnership
Heath Care Collaborative of Rural Missouri
HIT Network
Illinois Critical Access Hospital Network
HIT
-Have HIE capabilities, but communicating timely and
accurate information can be challenging
-Working on population health management registry
-Telehealth use in products like Jabber: secure video
system for tele-psychiatry
-HIE use
 Data sharing is relatively easy with use of associate
agreements, etc.
 Multiple HIE’s, but they’re interlinked
-Telehealth
 ED coverage for mental health
-Direct email use
-HIE use: statewide
-Different EHRs, some haven’t reached meaningful use
-Claims data will be key
-Telehealth-mostly tele-psychiatry but envisions expanded
use
Patient/
Family
Engagement
-Home visits are effective for patient engagement
-Patient empowerment and role modeling (pilot)
-Using the Coleman model of patient engagement
-Patient education focuses on diet and healthy living
-Small group work is effective as a diabetic focus
-Integrated health is focused on the patient: teams
working across disciplines
-Still in development stages but is expected to include
education and patient engagement
Business Model
-Currently relying on short term funding sources
-Developing approach to private payers to do care
coordination and patient education and empowerment
-Medicare shared savings program
-Preparing for pay for value by improving quality,
engaging patients in their own care and reducing costs
-Federal, state and private foundation grants
-Investments and dues from partners
-Considering shared savings models, shared costs and
ACO models
-ACO business models built on shared savings and high
quality
-BCBS negotiations for coordinating care for BCBS
populations
-Grants and contracts
Challenges/
Lessons Learned
Challenges:
 Getting support from all partner hospitals on a
common program or strategic direction
 Getting patients to accept coaches in homes, but
once they do they want them to come again
 Care coaches may not have clinical background to
see med errors, emergencies, etc.
 Accessing information in a timely manner
 Doctors are sometimes reluctant to go out of their
way to use a portal. It has to be easy
Lessons:
 It’s really important to get everyone in the network
to agree on something in the beginning
 Get buy in and support for network value strategies
 There is a lot of attachment to individual silos and
cultures that must be overcome
 It makes most sense to do care coordination for
everyone, not just small groups
Different providers have different skills and should work
as a team to the top of their licenses
Challenges:
 Broadband connectivity issues limit use of
telehealth
 Organizing different types of service organizations
is hard
 Having “tough conversations” with partner
organizations (payments, systems, outcomes, etc.)
 Identifying a specific patient population to focus on
 Finding adequate funding to drive health initiatives
Lessons:
 It’s important to identify a specific population to
work with
 Hiring the right staff that are passionate about
population health is key
Broad involvement of community providers, businesses
and patients provides a good foundation for value
Challenges
 Not knowing what it’s going to look like so you end
up putting it together as you go
 Different information technology and lack of reliable
informatics still a problem
 CAH lack of awareness of rapidly changing health
industry; sometimes resistance to these changes
 Finding the funding to go forward, and finding a
way to get paid for development and
implementation of care coordination
 Rural hospitals don’t have experience practicing
evidence based medicine
Lessons Learned
 Rural hospitals are probably more prepared than
they think they are, but general awareness of value
and care coordination is lacking
 Conducting readiness assessments before
implementation of care coordination is important
 Thinning the referral networks will be important to
achieve high quality at low cost
There is greater financial safety and shared knowledge
when approaching care coordination as a network of
hospitals
NATIONAL RURAL HEALTH RESOURCE CENTER
RURAL NETWORK CARE COORDINATION MODELS: COMPARATIVE MATRIX
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Rural Care Coordination Models: Comparative Matrix
Contact/
Location
Monida Healthcare Network
National Rural ACO
PrimeWest Health
Greg Drapes and Amber Rogers
Montana
Lynn Barr and Mary Bittner
California, Indian Michigan
Jim Przybilla and Karen Rau
Minnesota
Care
Coordination
Definition
-To help the physician or provider implement the
prescribed plan of care
-Part of a larger strategy of clinical integration
Partnering with a payer organization to lower cost and
improve care
-Organizing patient activities between care coordinator
coach, patient and care giver to ensure effective
facilitation and delivery of health care services within the
continuum, done in a patient and family centered manner
-An integrated approach, not one-size-fits all
-The right service, at the right time, right place, and at
the right price
-Finding the correct definition of ”right”
Primary care focused with patient-centered coordination
Network
Description
-Multi-county in southwestern Montana
-7 CAHS
-Tertiary Referral Center
-300 Physicians
-300 Non-physician providers
-National scope
-7 member hospital communities
 7 CAHs in CA, MI, IN
 9 FQHCs in MI
 1 PPS Hospital
-Plan for expansion 2015
 Average size: 10,000 lives
 7 ACOs
 9 states
 22 communities
-Multi-county health plan (enabled by special Minnesota
legislation)
-Managed care role (having a foot in both the provider and
the payer worlds)
-CAHs
-Rural hospitals
-Community medical centers
-Regional referral center
-Patients who do not have a regular primary care
physician
-“High use ER patients
-High risk heart disease patient
-High cost patients with multiple chronic illnesses
-Medicaid complex care patients
-Those with frequent ER visits/high utilizers
-Senior population
-All PrimeWest health plan members
Focus Population -Primarily diabetes, COPD, CHF and heart disease, most
have comorbidities
-Focus on decreasing ER admissions and hospitalizations
-Considering Medicare advantage plan members
Care Team
Members
-Care Coordinator (patient coach, not always a nurse)
-Nurse Leadership
-Primary Care Providers
-Pharmacists
-Dieticians
-Community Case Workers
-Behavioral Health
-Pharmacists
-Social workers
-Nurse leader
-Social Workers
-Pharmacists
-Dieticians, diabetic educators
-Physician leader
-Patient connection role; with unlicensed care staff
-2 Care Navigators
-Primary Care Providers
-RN Care Coordinators
-County contracted Public Health & Human Service
-Human Services
-County Case Manager
-Mental Health and Chemical Dependency—Rule 25
assessment and MH TCM
-Providers working at the top of their license
Partner
Organizations
-Third party payer organization
-Financial management party
-Public health
-Long term care organizations
-IHS
-Mental Health
-Public health
-Medical home (ACMC), share a 24/7 nurse hotline
-Hospitals
-Clinics
-Public Health
-Mental Health
-County Health and Human services
NATIONAL RURAL HEALTH RESOURCE CENTER
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Monida Healthcare Network
National Rural ACO
HIT
-6 different ambulatory EHRs
-3 main hospital system EHRs
-Get claims data from their third party payer partner
-No central registry at this time
-Created an access database with all the information, but
requires double documentation
-Have ability to do telehealth, but need to find ways for
better ROI. They get reimbursed the same as face-to-face
encounters, but must add in the line charges and staffing
costs.
-Single data warehouse for claims data
 ID areas of high cost or low quality concern
 Benchmarking
 Utilization
-Everyone on separate EHRs
-Tele-health
-Tele-psychiatry
Patient/
Family
Engagement
-In development stages
-Are using motivational interviewing to engage patients
-Can teach the class but have no way to monitor use by
the physicians
-In development stages
-Patient education and engagement
-Self-management and motivational interviewing
techniques
Business Model
-Get payment from the third party payer by fee for service
(FFS) use of certain CPT billing codes
-Employers would not participate in a managed care plan,
so they now do FFS based on CPT amounts, and Monida
gets a percentage back to them
-Care coordinator contracted from network, or hired
directly by network member
-Currently not taking on financial risk
Challenges:
 Some providers get excited about care coordination,
but the payment mechanism needs to catch up to the
excitement
“You can care coordination yourself into bankruptcy”
 Finding a way for the HIE to work with the diverse
EHRs
 Keeping everyone engaged in the process over time is
difficult
 Facilitating a complete change in culture is necessary
for the new payment models
 Finding the funding to facilitate development of new
models
Lessons:
 Some people will gain more control during the care
coordination process while others may lose control
 Physicians do not always want to do new work on top
of their own. They must understand the “why”.
 Education alone does not change behaviors, it takes
altered processes, culture change and resiliency
 It may be necessary to thin out the referral network,
which is difficult in very rural areas
-Cost: $120,000 per year per hospital
-Shared savings models to repay investment
-Future ideas: assuming risk for savings and quality
Challenges/
Lessons Learned
NATIONAL RURAL HEALTH RESOURCE CENTER
Challenges:
 All members having different EHRs
 The huge start-up costs,
 Initial reduction in utilization for hospitals still having
to live under old payments
 Crossing the “shaky bridge” between payment models
 Concern of physician disillusionment during the
change process
Lessons:
 Find scalable efficiencies and quick wins
 FQHCs have longer history of care coordination and
are generally ahead of hospitals
 Claims data is hugely important to reduce cost and
identify quality providers
 Can’t use a one-size-fits-all approach; every hospital
and community is different
 Care coordination across community services is
difficult because of historic lack of communication, and
health services silos. Hospital coordinators sometimes
reluctant to engage mental health or aging services
RURAL NETWORK CARE COORDINATION MODELS: COMPARATIVE MATRIX
PrimeWest Health
-Electronic care plan for documentation, acts as an HIE
 Care plan platform
 Progress notes (from patient assessment)
 Accessed by all members of the care team
 Can attach elements to it
-Access to PrimeWest cloud-based claims data
-Tele psychiatry/psychology
 Connected in 13 counties and established
reimbursement
-Video units in distant communities for medication therapy
management of elderly population and consultation
function between psych and PCP
-Seniors and disabled members each assigned a county
case manager and a health plan care coordinator
 Proved those assigned a case manager have better
outcomes overall
-Care navigators: outreach, help make appointments and
also help get patients in
-Care coordination fees through PrimeWest
-Shared savings through better care coordination
Challenges:
 Not all EHRs in their network are programmed the
same: coordinators may have access to see a part
of a record in one clinic, but not in another (even
under the same EHR system)
 They are doing most of the data analysis on their
own, because health facilities don’t have the
knowledge, skill and abilities on staff
 Less autonomy to act at a community level when
metropolitan based systems are involved
Lessons:
 All of the data can really help providers, if they are
willing to use it to improve quality and reduce cost
 They must provide expert technical assistance,
adequate support and technical consulting when
entering into shared savings with providers because
they may not be accustomed to seeing/analyzing
health plan data
 The challenges and requirements of effective care
coordination are often unknown or underestimated
by hospitals and clinics
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